Provider Demographics
NPI:1447256680
Name:LISS, FREDERIC ELIOT (MD)
Entity type:Individual
Prefix:
First Name:FREDERIC
Middle Name:ELIOT
Last Name:LISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST
Mailing Address - Street 2:SUITE 1402
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4414
Mailing Address - Country:US
Mailing Address - Phone:800-321-9999
Mailing Address - Fax:267-339-3761
Practice Address - Street 1:400 MAIN ST
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-3810
Practice Address - Country:US
Practice Address - Phone:610-935-1120
Practice Address - Fax:610-935-5507
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036317E207X00000X, 207XS0106X
NJ25MA09448300207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1292527Medicaid
429395G3DMedicare ID - Type Unspecified
PA0368600001Medicare NSC
PA1292527Medicaid